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BUILDING. INSPECTOR RECORD <br />SITE-WORK DATE !D/SIG.COMMENTS ()WNER BU II,I)ER I )}:I,L-A RATIoN <br />I h!'rchy atlirnr undcr pcnally of pcrjury lhil I am ctcmpl li1)m lhc (inilrack)rs l-iccnsc Law li)r lhc ti)lk)willg lcaron (Scc.7031.5 <br />Busincss and Proltssion Crx!c): Any Cily r)r Counly which rcquircs r Frmil lo conslrucl. alrcr. improvc. dcmolish or rcpnir ary <br />slnrcltrrc.pri()rloils issuatrcc.alsorequircslhcapplicantli)rsuchJrrnrillotilcisigncdstatcnrnt thathcorshcisliccnscd furuant <br />lo lhc provisions o[ thc Conlrack)r's Liecnscd Law (Chaplcr 9, Conrrcncing wilh Scctt)n 70{)0 ol Divisirm .] of thc Rusircss and <br />rppliclnlli)rapcrmilsuhjeclslhc rpplicanlk)acivilpcnlhyolnotnx[cthanfivchundrcddollrs(S50(r,. <br />. <br />_1. as owncr ol thc proJErty, or my cmpk)yccs with wascr rs thcir solc ((,nllcnrnli()n, willdo lhc work utd thc slnrclrrc is trol <br />ililordc(l orollarcdli)rsnlc(Sce.7(N4,BusilrcssandProl'cssionsC(xlci'lhcConlrlct(njsLiccnsc[-iwdoesnolalplyt()nnowncrof <br />thc pn)Frty whi) hrilds or inprovcs llEAnl. iurd who d(Es such work hurscll'or hcrscll or thn)ugh hir or her own cmployccs. <br />prolidcd that srch impft)\cnrnts trc not iltcBlcd orolllBt lilr sah. lt. howcrer. llt huilding or inur(,\cmnt is sokl within onc yci( <br />saL'). <br />I. rs ()wner (,I lhc pfl)pcrly. am c\clu\ivcly contractrrtt wilh liccnsc(l ronlrack)rs k) crmslnrcl ll[ pro.iccl (Scc. 7(144. Businc\s <br />a,x] [\)tlss(m(i)dc:ThcContrrctor's[-iccn\cLawdr)csnotrpi'lyloail()wncroffrolrertywhohuildsorinlFrovcsthcrc(ilt. <br />and who e(trrtrrcts li)r sueh projccts with a ('orilraekn1s) liccnscd pulsudnt m thc (i)nlractor's l,iccnsc [-aw). <br />-IantcxcmplUnJcrsccli(trl-.t].&P,C,ti)rlhisrcason <br />IvoRKERS' COI\lPl:NSATION <br />I)ECl,Atut IlON <br />I hcrchy alfirnr un(!er Nnrltv ol JNrjury onc rtl lhc Ii)lk)wtru (lcchralir)D\l <br />_l hrvc md will mrintairr r Ccrliticxtc of Conscnl k) Scll:lnsurc fi)r workcrs conlFrcnsati(nl. as prolidcd tbr hy Scct()n l7(X) ol the <br />lnh([ Codc, Ibr lhc pcrfi)rnratrec of thc work li)r which lhc pcrmit is issucd. <br />_l hnvc <br />lhc work <br />and will maintain workcrs' compcnsali()n insurrmc. as rcquircd hy Seclil)n .1700 oflhc [-ahor C(]dc. for thc lErfomuncc of <br />tbr which this pcmit is issucIj. 14y workers' compcnsation insurancc canicr ud Jxrlicy numhcr eci <br />4rWi-r.,-d ' <br />,taricr: <br />\ Poliey tL) <br />_l ccrtily thdl in thc pcrli)rnuncc of thc work lbr which this pcrmit i\ issucd. I shall not cmpl()y rny pcrs{)n ii rny manncr <br />s() {s lo tEcomc suhjcel k) llc workcrs'cotrrpcnsali()n laws ol'Cdlil()rnin. ilnd agrcc lhal il I should hccom suhicet to thc <br />workcrs coilrpn\atir)npruvi\tr)n\ofScct!n17fi)olthel-rh)rCqJe. lshrll. linlhwitheonrplywiththr*pnrvisirrrs. <br />IVARNING: l:alhrrc lo scilrc workcrs'comncnsiti()n (r)vcra8c is unhwlirl. anil \hill \uh.icct an cnrpkrycr to cnntinal lEnrltrs and <br />civil lincs up k) onc htndrc,l lh(trrsand dollars ($ltX).lXX)). in addili()n k) thc cosl ol compcnsdlion, danraqcs as pr()vidcd li)r thc <br />Sc( l x)n .1076 ()l lhc I -rlxn (irl( . inlcrcsl rD(l rlt[)cy s li.c\. <br />Itro-U CItuurr--O(t - <br />LICENSED CONTRAf]TOR <br />DECLARATION <br />ol lhc Busincss and Proltssions Codc. ail nty liccnsc is ur lirll fi)rcc inJ cllccl. <br />/'214Class: v 1' I Liccnsc Numtrcr:1o/t)n/ <br />i 9)n91?c- <br />I <br />I hcrchy allirm undcr JEnllty of Frcrjury that thcrc is a conslruclhn lcnding a!:ency fi)r lhc lErfomancc of lhe work tdr which lhis frcmil is <br />issuctl (Scc. .1097. Civ. C.). <br />k'nrlcr's Namc: <br />bndcr's Arldrcssr <br />APPI-ICANT DECI,ARATION <br />I l*rchy all'rmr undt'r pcnalty ol pcrjtry one ()t lhc t'olI)wir8 dcelarali(rls: <br />Dcm)lition Pcnnits-Asbeslos Notilicalirr fcJcral Rc{uhli(,ns (Tillc 40. Prrl6) <br />-Rcquircd <br />l-ctl!'r r)f Noliliralrtr <br />I ccrlify lhrl lhc tidfl'xl rcgulali(Ds rc!ardiD! ishcsk)s rcrnovxl .rc nol xflllicrhlc t() this pft)iccl. <br />_l ccdili thal I hrvc rcarl thrs applicati(trt :ud slite lhal thc nhrvc inli)rnrati(trI is corccl. I agrcc k) corrlly with all Ciry nnd Coutrty <br />ordinanccs and Strtc l-aws rclnting to ol lhi\ Cily and (itrrDly lo cnrcr ulxnr lhc <br />above rrrcrrlirilcrl In()pcrly li)r <br />I <br />D,," ol^ 0l --N <br />Set Backs <br />Forms/Steel/Holdowns <br />Erection Pads <br />UFER Ground <br />SLAB Floor <br />Subf loor/VenVl nsulation <br />Roof Sheathino )/r,fhdb ru f(1,k7-l <br />Shear Wall <br />Framinq <br />lnsulation/Energy <br />Drywall <br />Ext./lnt. Lath <br />Brown Coat <br />[Vasonry <br />Pool Fence <br />T-Bar <br />Handicap Req <br />Deputy Final Report <br />Enqineer Final Report <br />Flood Zone Certif <br />FINAL /tL+?2 E'6lte. <br />Certificate of Occupancy <br />Notes, Remarks, Etc <br />a-ob-N